Medical Education Column,Creating a High-Yield Guide to Lifestyle Medicine for Medical Students and Healthcare Professionals

Abstract

Despite their inclusion as first-line therapy for many chronic diseases, lifestyle interventions are often de-emphasized in medical education and fail to make it into the repertoire of non-lifestyle medicine trained clinicians. We sought to address this gap in medical education by creating a concise pocket guide to lifestyle medicine that lends itself to use in the face-to-face clinical setting. With input from lifestyle medicine experts, the guide was created by medical students for medical students as well as other healthcare professionals for use in a variety of clinical settings. In this article we share our process of creating the guide, initial feedback, and future directions.

“The diseases caused by these unhealthy behaviors represent billions of dollars in healthcare spending and thousands of quality-adjusted life years that are lost each year to preventable and reversible causes.^2,3”

Outside of the effects of the COVID-19 pandemic, the leading causes of morbidity and mortality in the US are related to lifestyle, including but not limited to physical inactivity, tobacco use, unhealthy eating patterns, and excessive alcohol consumption. ¹ Despite the need for lifestyle intervention, physicians are often not enacting the first-line treatments for these chronic conditions which often include counseling and lifestyle modification. For example, recently patients with BMI greater than 30 received counseling to lose weight only 36% of the time during primary care office visits, and only 28% of smokers report being offered help quitting in the past year.^4,5

At least part of these deficits can be explained by a lack of attention to lifestyle behavior topics in formal medical training. For example, only 27% of medical schools report they provide 25 hours of education on nutrition and only 6% report a course or required curriculum on exercise prescription.^6-8 As medicine continues to become more advanced both technologically and pharmaceutically, there is less and less time for education about topics that are deemed to be less important such as dietary recommendations and exercise prescription. Currently, the resources available for medical students seeking an all-encompassing guide to lifestyle medicine come in the form of a comprehensive textbook titled “Lifestyle Medicine” edited by Dr. James M. Rippe, which introduces the field as one based in science and rooted in academic rigor. ⁹ This textbook provides the latest research articles and shines a light on the landmark studies important to the practice of lifestyle medicine. Another offering is the “Lifestyle Medicine Handbook” by Drs. Beth Frates, Jonathan Bonnet, Richard Joseph, and James Petersen that delivers a more abbreviated overview of lifestyle medicine with a focus on behavior change in its 400 pages. ¹⁰ These resources are ideal for medical students and health professionals looking for extensive academic resources.

As medical students (co-presidents of the medical school’s Lifestyle Medicine Interest Group [LMIG] and entering clinical training), we needed a simple, small, data-driven manual that could be used in the clinic or by the bedside that delivered clear advice and counseling tips for patients in primary care, perioperative, inpatient, and other clinical settings. Therefore, we created the Lifestyle Medicine Pocket Guide (LMPG) structured around the 6 pillars of Lifestyle Medicine, with a chapter dedicated to each pillar, and also including an individual chapter on coaching and behavior change due to its foundational role in lifestyle medicine and direct relevance to the application of each pillar with individual patients. We were guided in this effort by Dr. Beth Frates MD, FACLM DipABLM, who is the faculty advisor to our Lifestyle Medicine Interest Group. Dr. Frates also serves as the senior author of the LMPG.

Each chapter delineates three key components of a given pillar. First, why a pillar is important and the essential background a healthcare professional needs to deliver information regarding that pillar. Second, the evidence-based health benefits of a pillar and how to communicate the information and data effectively and concisely. And third, the tools available to healthcare professionals to help them discuss a pillar with a patient and initiate behavior change. There are tables and lists in the chapters to help organize the material. When possible, we use figures or diagrams to help readers visualize concepts.

We start each chapter with a hook on the importance of each pillar and discuss data at a population level to give background to the reader. We include sections that are variable from chapter to chapter to give specific context on a pillar by defining important terms and concepts such as types of activity in the physical activity section and common diets in the nutrition section to allow students and healthcare professionals to appropriately understand and interpret subsequent information in that chapter.

For the second section, we address the key health benefits of a pillar in two ways. First, we cover the physical and mental health effects of a given pillar. We organize the section by disease process and incorporate data from primary research with references so that healthcare professionals can quickly cite empirical data relevant to a given patient and lifestyle intervention. Then, we provide a table summarizing all the effects of a behavior, organized by organ system, to consolidate the information for easy and efficient viewing and as a potential reference to show patients.

In the third section, we share commonly used and validated screening tools for lifestyle behaviors so that healthcare professionals are equipped to screen for potentially risky behaviors. We also formulate our own high-yield questions based on expert input from experienced lifestyle medicine clinicians for healthcare professionals to engage patients in conversations regarding specific pillars and behaviors. While not validated, these specific questions have been personally incredibly useful in generating open and productive dialogues with patients. Lastly, we discuss pillar-specific strategies for behavior change ranging from sleep hygiene in the sleep section to suggestions for cultivating high-quality connections in the social connection section.

In alignment with the data-driven focus of the lifestyle medicine pocket guide, we plan to validate the usefulness of the guide in a randomized trial. We will deploy the guide to first and second year medical students undergoing objective structured clinical examinations (OSCEs). Students will be asked to evaluate how comfortable they are providing lifestyle guidance to standardized patients. Then half of the students will receive a copy of the LMPG and half will not, and then they will conduct on OSCE during which they will be expected to counsel a patient on a facet of lifestyle medicine (tobacco cessation, weight loss, and exercise prescription). Finally, we will conduct post-surveys on how confident they felt providing lifestyle guidance including specific evaluation of their knowledge of the literature, specific vs general recommendations, and their ability to integrate lifestyle medicine with their knowledge of basic sciences and the pathophysiology of disease. We also hope to expand the guide into further volumes, with Volume 2 addressing other important aspects of lifestyle medicine, such as global health, health equity, planetary health, medical student wellness, burnout in medicine, and how to navigate medical school.